Thoughts on medicine in sports

November 10, 2009

The apparent suicide of 32 yr old German goalkeeper Robert Enke is a grim reminder of the vulnerability of athletes to depression, as mentioned in a previous post. Missing time recently with the national team due to illness as he was fighting for a spot on the World Cup roster probably did not help his state of mind.

November 04, 2009

San Antonio Spur Manu Ginobli caused quite a stir recently when he swatted a bat out of mid-air during a recent game - on Halloween no less:

I love how the athletic trainer is on the spot with some hand-sanitizer at the end of the clip. That move looks even better now that Ginobli has announced that he had to be vaccinated for rabies.

My initial thought was that the shots seemed like a bit of typical professional sports medical overkill until I read the CDC's page on bats and rabies. The rabies virus is transmitted from infected animals to humans either by bite or more rarely if infected material such as saliva gets into your eyes, nose, mouth, or an open wound. Surely Ginobli would have known whether or not the bat bit him wouldn't he? Not necessarily as apparently bat teeth are so tiny that a bite victim may not even know that his or her skin has been punctured.

Consider this chilling case report:

In February 1995, the aunt of a 4-year-old girl was awakened by the sounds of a bat in the room where the child was sleeping. The child did not wake up until the bat was captured, killed, and discarded. The girl reported no bite, and no evidence of a bite wound was found when she was examined. One month later the child became sick and died of rabies. The dead bat was recovered from the yard and tested--it had rabies.

As the stunned and captured bat was released outside of the arena - which still didn't keep the PETA folks off of Ginobli's back - the bat in question could not be tested, so he prudently opted to get vaccinated.

October 21, 2009

From the posts on optical illusions in sports file, a really interesting Purdue University study shows that recent performance can cause our eyes and brains to play tricks with how we perceive the world around us:

The researchers used a small, adjustable replica of a (american football) goal post to test players’ perception before and after attempting 10 (field goal) kicks. While standing in front of the real-life goal, participants were asked to adjust the width and height of the model to scale.

The players’ pre-performance estimations didn’t correlate at all with their subsequent success rate. But after 10 field goal attempts, their perceived goal size was highly correlated with peformance.

Interestingly, the change in players’ perception didn’t just depend on how many goals they missed — it also mattered how they missed their goals. Folks who failed because they didn’t kick high enough perceived the crossbar to be taller, while those who kicked to the side viewed it as more narrow.

October 14, 2009

- A South Carolina golfer lost an arm when he was attacked by a 10 ft alligator while trying to retrieve his wayward ball from a pond. The arm was recovered but it doesn't sound like they were able to reattach it. That is a harsh penalty for hitting into a hazard.

Golfers also need to be on the look out for snakes (example 1example 2) when looking for that lost Titleist.

- A 7 year old Ohio boy was tackled by a blitzing deer during a backyard football game. Fortunately young Wyatt Pugh was OK other than bruises and a laceration.

The official friendly site Proreferee.com is skeptical since the video is strategically censored and none of the players react, but why let that stand in the way of a chance to educate soccer fans, players, and officials about prostate health?

September 24, 2009

The leader of India's cricket team wants his players to have more sex. In addition to trying to earn votes from his guys as "coach of the year", Gary Kristen hopes the plan will boost on-field performance. He has circulated a document to his cricketers about preparations for this weekend's match against arch rivals Pakistan. A reported excerpt from a document circulated to the team:

"Does sex increase performance? Yes it does, so go ahead and indulge", before detailing the benefits of a good sex life and even suggesting "going solo" if no partners were available.

Why would team leaders encourage such reckless behavior? After all, another term for orgasm is "le petit mort", the little death. Indian fans don't want their heroes to be losing a little bit of their life force the night before the biggest match of the year do they? And doesn't abstinence lead to sexual tension and frustration that then naturally manifests as heightened aggression?

"From a physiological perspective, having sex increases testosterone levels, which cause an increase in strength, energy, aggression and competitiveness," the document said. "Conversely, not having sex for a period of a few months causes a significant drop in testosterone levels in both males and females, with the corresponding passiveness and decrease in aggression."

A 2000 review of the literature on this hot topic in the Clinical Journal of Sports Medicine found no evidence that intercourse the night prior affects any physiologic performance measures.

Another drawback of abstinence is that an athlete may be, um, distracted by this tension and misplace his priorities. Put another way by the sports version of the Kama Sutra:

"You may experience that your mind spends more time focusing on the fire in your groin than on good sport practice, preparation and sleep,"

While there are studies on physiologic impact of sex, the psychological effects have not been researched. The authors of the CJSM review postulate that the mental tension/aggression of abstinence vs. the relaxation/happiness of recent sexual activity may be good or bad, it all probably depends on the sport and your personality to begin with:

According to the current inverted U sport psychology hypothesis, there is an optimal level of alertness/anxiety before a competition, and a poor performance will result from either being too anxious or not alert enough. If athletes are too anxious and restless the night before an event, then sex may be a relaxing distraction. If they are already relaxed or, like some athletes, have little interest in sex the night before a big competition, then a good night's sleep is all they need.

The Indian cricket staff was smart enough to include this important qualifier:

The document quotes Tim Noakes a professor and sports scientist at the University of Cape Town, Kirsten's home town, as saying that "sex was not a problem, but being up till 2:00 am, probably having a few drinks at a bar while trying to pick someone up, on the eve of a game, almost always was."

However the results of future research on this subject turn out, I think those of us at the college level will probably stick with taking the team out to a (mainstream) movie the night before a game.

September 23, 2009

A recent article in the San Francisco Chronicle questions the necessity of testing NCAA athletes for sickle cell trait and claims such a policy could also lead to discrimination against minority players.

A quote related to the first point:

...in several cases where athletes with the trait died, doctors found evidence of "sickling" in their blood cells. Vichinsky and other doctors say researchers don't know if the sickling was brought on by intense exercise and played a role in their deaths, or if the blood cells took on the sickle shape after death.

But there are studies that have shown that those with sickle cell trait "are markedby biological and clinical differences in comparison with subjectswith normal Hb". I would also add that the clinical presentation of those with presumed sickle associated collapse (exhaustion early in an intense workout) seems to be different than that of heat stroke (elevated core temperature, often dehydration, after exercise of a longer duration) indicating that they are distinct entities.

And the second point:

Some doctors and ethicists said it's easy to imagine some coaches easing up on athletes with sickle cell trait, especially since there has already been a lawsuit.

"The idea is coaches are supposed to work out an individual plan with that athlete, but unconsciously you can imagine they're going to be worried about their liability," said Marsha Treadwell, who works with patients at Children's Hospital's sickle cell center. "Those athletes are not going to get the same conditioning."

I'd argue that we probably have no choice. They absolutely shouldn't be pushed as hard because doing so puts this type of athlete at risk.

Now I am always sensitive to the notion, as is raised in the article, that we should have to prove a condition is risky or an intervention is effective before it is mandated. The sudden cardiac death screening debate is an excellent comparison. I haven't seen evidence to convince me that it is worthwhile to screen all athletes with an EKG or echocardiogram. Sickle cell trait and sudden death faces the same challenge when it comes to ressearch - deaths are rare so it takes huge numbers and lots of time in order to see if you've made a difference. As I've mentioned before, I think the decision to go ahead with sickle cell testing is easier than cardiac screening issues because A) the test is already done on everyone B) there is no gray area with the test, either you have the trait or you don't C) those indentified with the condition do not have to be restricted from play, just educated.

I do think it is reasonable to study whether or not such screening engenders any feelings of discrimination among athlete populations. If testing is offered to all ethnic groups - as it should since sickel cell trait affects other groups besides those of African descent - and all involved are educated adequately on the nature of the condition and how to prevent complications then I would think we can avoid any ethical quandries.

September 21, 2009

Two quotes from this story about H1N1 hitting the Florida Gators football team raise concerns:

"We're trying the best we can, but it's real," Meyer said. "We go to the extremes. They get a separate dorm room for them. They get a separate hotel room for them. They put them right on whatever the flu stuff is. Our guys, our team doctors, they're on it as fast as you can get on it."

Demps, who had a 101-degree temperature, ran four times for 31 yards and a touchdown...Meyer said Sunday that Demps probably shouldn't have played. "Jeff did not look right." Meyer is most concerned about Demps for this week since he was still "on the front end of the flu" (!)

Previousposts about H1N1 discussed H1N1 developing some resistance to anti-virals and the need to lmit their use for treatment and prophylaxis to those with medical conditions that put them at risk for complications. Assuming the coach is talking about anti-virals like Tamiflu and not simply supportive care treatments Should a different standard apply to the #1 team in the nation?

Also, an athlete with a fever should not play or practice (or go to class, hang out in the cafeteria, etc) so as not to expose others to the infection. Maybe, in retaliation for Tennessee coach Lane Kiffin's trash talk about the Gators this summer, Meyer and company decided to smite the Volunteers with swine flu rather than running up the score. Also, exercising with a fever puts the individual at risk for heat illness, dehydration, and exacerbating the infection.

September 19, 2009

Remind me, what was this supposed to accomplish? The results of the IAAF "investigation" to "determine" Caster Semenya's "gender" were unbelievably leaked to the press. Reports that she is a "hermaphrodite" (do we need more air quotes to convey my intended sarcasm?) have resulted in her needing to be on constant suicide watch. Because of the slippery nature of gender and the public scrutiny she'd be subjected to, Semenya was destined to be the loser from the moment this witch hunt began. If athletes are at high risk for depression and suicide when their identity as a competitor is threatened, imagine the impact when one's gender identity is threatened - while the whole world watches.

Coach responsibility. Kentucky high school football coach David Jason Stinson was found not guilty in the heat stroke death of one of his players, 15 year old Max Gilpin, last August. What I hope comes out of this tragedy is not what liability do coaches have but rather what responsibility they have. If coaches are going to enjoy the mythic role our society grants them - educators, molders of men, a leader who happens to be a coach - then part of deserving that role is to step up and take an active part in keeping athletes healthy. Kentucky is not taking any chances:

Kentucky lawmakers this year passed legislation that led to a
four-hour online course for coaches on emergency planning and
recognition; temperature-related illnesses; head, neck and facial
injuries; and first aid.

Jefferson County Public Schools
also now require all athletes and at least one parent to watch a
40-minute video that touches on everything from dietary supplements to
bacterial infections. Local high school coaches must attend a seminar
on using positive reinforcement when dealing with students.

Here in North Carolina, the HSAA has taken similar steps to educate parents and coaches with mandatory slides about concussions and heat illness added to the required eligibility presentation before each season.

The coaches who attended our medical crisis management workshop here at the WFU Center for Applied Learning were great, really throwing themselves into being a part of the team that is responsible for the safety of their athletes. I think they realized that they could make a critical difference by recognizing dangerous situations, contacting emergency medical services, providing basic life support, providing crowd control, insuring EMS access, and assisting with equipment needs.

September 10, 2009

The Stanford Cardinal football team travels across the country to play here at Wake Forest this weekend. Considering the potential impact of jet lag on performance and what happened to fellow Pac-10 member Cal last year, you would think a west coast team would never agree to a noon kickoff on the east coast.

The first is a mismatch between circadian rhythm and local time. The body's internal clock controls the regular physiologic variations that occur over a 24 hour cycle. Body temperature (and probably other factors like forebrain activation and hormone release) is lowest at 6 AM and peaks at about 9 PM. Athletic performance could mirror these body function peaks and valleys. This theory is partially supported by a 1985 paper which found that athletic performance was best between 12 - 9PM. The position statement authors rightly point out that perhaps, rather than circadian rhythm, we do worse with exercise in the morning because we've recently been in bed for 7-8 hours meaning we haven't eaten much or our muscles are stiff and cold.

The other purported mechanism is what we usually think of when it comes to "jet lag" - a disruption of the sleep-wake cycle. Simply put, you fly from the west to the east coast then don't feel like going to sleep until 2 AM local time because your body is still operating on pacific time, but have to wake up at 7 AM to get ready for the business meeting or game or because the sun lights up your room, and the result is you are tired from only getting 5 hours of sleep.

Either way, the bottom line is that air travel across time zones seems to have an independant effect on team results. A 1993 study in Medicine and Science in Sports and Exercise looked at the win-loss records of NFL teams from 1978 - 1987:

Now consider college football teams who, due to budget restrictions and the need to minimize missed class time, have to fly in the day before a game. In order to eliminate a potentially unfair competitive advantage for eastern teams, the NCAA should consider a rule that says games involving a team that has travelled across 2 or more time zones have a kickoff time no earlier that 3 PM. At the very least western athletic directors should go by these parameters when working out game times with eastern schools or the television networks. I guess some could argue that trying too hard to even the playing field - as mentioned in this past post about FIFA backing-off its attempt to eliminate high-altitude matches - would reduce some of the variety and intrigue that makes sports interesting.

Another argument against making an actual rule is that the possible negative effects of cross-time zone travel may be limited by some simple planning. The FIMS postion statement describes how circadian rhythms can be advanced or delayed based on light exposure and/or light exercise at certain times of the day. I utilized these techniques when traveling with a US soccer youth national team to Japan, putting the guys through a light workout by a bank of windows in the Tokyo airport at the optimal time while we waited for our connecting flight to Nagoya. Just having a plan seemed to help inspire confidence. The coach, trainer, and I also agreed not to even mention jet lag after that first day in order to avoid any psychological impact. Now we did lose our game to the host country two days after arrival so maybe the strategy didn't work, but on questioning the team at the end of the trip all reported feeling really good the day of that first game and we were the only team in the tournament to even score on Japan so maybe it did have some benefit. Uruguay definitely wished they had planned ahead for the travel stress involved in their home-and- home playoff with Australia for a spot in the 2006 World Cup finals - they had to take a multi-leg commercial flight across the pacific while the Socceroos flew in a custom charter plane with seats removed to make room for beds, massage tables and UV lights. The fresher Aussies go the result they needed in the second leg and advanced.

The body clock can be manipulated even before the trip. One west coast team in the 93 NFL study held practices 3-4 hours earlier in the day than usual to match the upcoming east coast game time which resulted in a winning percentage 2.3% better than expected. Gradually adjusting bedtime and wake time closer to that of your destination can be helpful in the same way. Again, unlike a professional team a college squad may not be able to hold practices at 9 or 10 AM due to class schedules.

Interestingly, both the MSSE study and a paper in the journal Sleep found that NFL teams from the west coast do better than expected against east coast teams when they play at night whether the game is in the west or east! Maybe east coast teams just can't handle the prime-time pressure of Monday Night Football....or when the Seattle Seahawks play a nightgame in New York they can sleep in later on game day and/or they are close to their home time zone late afternoon circadian peak while the hosts are sliding towards the late night performance nadir. So a college team in the east that willingly agrees to schedule a west coast team for a night game - as Ohio State has done both this year and last (a 35-3 loss in Los Angeles) - is a sucker.

Of course, maybe we just all need to suck it up a little bit instead. As the case report of one rugby player in the British Journal of Sports Medicine suggests:

He played in the first two tests before flying to France. Fromthere, he was convinced to come out of retirement for severalfurther matches in Great Britain and France. He flew back toNew Zealand, a distance of approximately 20 000 km (and 12 timezones) to be present at the birth of his son by elective caesareansection on 24 November 2005. Although back in New Zealand, heheard that his Kiwi team had qualified for the Tri-Nations final.A few hours after the birth, he boarded a plane to fly backto Great Britain, a further 20 000 km and 12 time zones. Hearrived in Manchester just 1 day before the final match. Hehad flown to New Zealand and back (some 40 000 km) in a spanof 6 days. His performance in the final was up to its usualhigh standard, directing play effectively, plus he kicked aconversion and three penalty goals.